Pneumonia is a Disease. Is High Cholesterol or Osteoporosis?

So much of what we do today in medicine falls in the gray zone between treating disease and manipulating risk. I am not sure how many “patients” and how many “providers” fail to ponder or make the distinction.

(I put “patients” in quotation marks, because I wonder if we should use that word for people who aren’t sick…)

In many cases, we have ended up with disease-like names, and drug based treatments, for these risk factors. In reality, many other things besides drugs can modify these risks, but our “scientific” paradigm mostly recognizes double blinded trials of medications and undervalues other approaches.

Cholesterol and heart disease are prime examples of how simplistic and ignorant we have been and how “medicalized” our thinking has been:

While extremely high cholesterol sometimes is a genetically determined abnormality, for example Friedrichsen’s hyperlipidemias, garden variety high cholesterol is a laboratory abnormality that evolves and can change according to a person’s diet and lifestyle.

For decades now, we have treated “high” cholesterol with statin drugs, and we now have statistical “proof” that they reduce a person’s risk for strokes and heart attacks. This is the case even for people with “perfect” cholesterol, but the absolute risk reduction isn’t as impressive as the relative one. After all, half of next to nothing isn’t as impressive as half of a very large number.

But, and we know all this although we don’t talk enough about it, since non-statins like ezetimibe (Zetia) can also lower cholesterol without giving anywhere near the same degree of risk reduction, it’s not really about the cholesterol reduction at all. Every day I rattle off to patients that the statins stabilize and prevent rupture of cholesterol plaque, prevent plaque buildup in the first place, prevent blood clots via a mechanism different from aspirin and prevent contraction of the little muscles in the walls of coronary arteries that cause coronary spasm. And I explain that although we know these mechanisms exist, we can’t measure their effects in patients. I also mention that in older persons, a Mediterranean diet causes about the same risk reduction as statin drugs do in middle aged people. It lowers cardiovascular mortality by 30% compared with the old standard low-fat diet.

The new lipid guidelines have a calculator that provides a ten year cardiovascular risk. That helps people by providing a risk number they can relate to, but then the “experts” arbitrarily decided that people with 5 or 7.5% ten year risk should be on low or high dose statins, respectively. The only problem is that all men over 67 or so should be on drugs. Common sense gets in the way of adopting that one, at least in my book. When age as a risk factor outweighs the truly variable measures, like blood pressure, shouldn’t we modify or scrap our disease paradigm?

Another example of a questionable “disease” is osteoporosis. The average woman’s bone density enters the osteoporosis range somewhere around age 80, and the average 60 year old woman has osteopenia. The universality accepted “T-score” compares everybody to a 30 year old. The “Z-score”, on the other hand, compares women to individuals their own age. Today’s guidelines suggest labeling the average baby boomer woman as having a disease, and also many women with better than average bone density. So we are told they are candidates for more or less scary but certainly not innocuous medications.

That reminds me of my residency days, when I would get my hand slapped if I didn’t put every postmenopausal woman on estrogen, because she was obviously estrogen deficient, and we even had the blood tests to prove it. The theory was that since older women had more heart attacks than younger women and the biggest difference(?) between them was their estrogen levels, all we had to do to wipe out heart disease in postmenopausal was to supply them with a lifetime supply of estrogen.

What happened, as the Women’s Health Study demonstrated, was that older women on estrogen plus progesterone (to protect from overstimulation of her uterus lining and subsequent endometrial cancer) had MORE heart attacks, strokes, breast cancers and blood clots than those who allowed their natural aging process to continue.

Today, the same thinking takes place with men and testosterone as the pharmaceutical industry continues its quest for the fountain of youth.

The ultimate question is to what degree aging is a disease and whether it should be the priority of the medical professions, pharmaceutical industry and our insurance system to fight it.

3 Responses to “Pneumonia is a Disease. Is High Cholesterol or Osteoporosis?”

We once tried to have all our patients euboxic. Cholesterol is a very interesting discussion. If you look at medical records of the pre-statin era, the lab reports included cholesterol and triglyceride normals with the usual 95% confidence intervals that it used for other lab testing. Those intervals are far higher than the targets that we have now. One could argue that the incidence of hypercholesterolemia is more than 2.5% which would be the two standard deviations of a sample population for that value. Most lab results fall on a continuum so the normal can be defined as either the 95% two SD interval or it can be defined as the marker of a condition. We see the reverse of this in thyroid disorders where the normal tsh rises with age but the 95% confidence interval calculates from the total population. A tsh of 8 in a 90 year old is normal but will be flagged on a lab report.

Osteoporosis has the same challenge. I just saw a lady for dm. At age 61 she had a kyphosis so I got a dexa. I could have gotten a t-spine film, identified the fracture, justified bisphosphonate on that basis but without the dexa I would have no means of defining the progress of therapy. The same can be said of lipid interventions, asymptomatic incidentalomas of no clinical consequence, most skin lesions. There is a lot of arbitrariness to defining what is a disease but some type of standardization is needed if we are going to be able to assess the efficacy of anything we choose to do.